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EW SHOW DAILY 36 ASCRS Symposia Sunday, May 7, 2017 by Rich Daly EyeWorld Contributing Writer "There are a variety of import- ant macular diseases that are flat out invisible with" that approach, Dr. Charles said. Dr. Charles said some surgeons perform OCT only on their premi- um IOL patients but noted "unhap- py patients are unhappy patients, whether they paid for a new tech- nology IOL, aberrometry, femto, torics, or multifocal lenses." Surgeons are seeing more central serous retinopathy (CSR) in an older age group, which can be linked to the large numbers of patients who are unknowingly taking systemic steroids. Systemic steroids come through sinus medications, asth- ma inhalers, pain injections, and dermatologic treatments. Dr. Charles found the rate of systemic steroid use in one glaucoma clinic was 50%. And the best way to detect CSR is fundus autofluorescence and OCT. "You can look at the fundus all day long with a 90 D lens under a contact and you won't see it," Dr. Charles said. The use of OCT is beneficial even in patients who already know they have some early symptoms of O ne way to avoid post-cata- ract surgery vision surpris- es related to the retina is through broad use of opti- cal coherence tomography (OCT), according to Steve Charles, MD, Memphis, Tennessee. "There are many invisible, important diseases that cause visual loss, many of which are only seen on OCT and fundus autofluores- cence," Dr. Charles said. "Patients are not happy if you get the cataract out, put a lens in, and they don't see better." The use of spectral domain OCT to identify retinal disease often is overlooked before cataract surgery because of fragmented care between ophthalmologists and optometrists and a lack of macula expertise by cataract surgeons. "There's a disease process that can be seen only with OCT," Dr. Charles said. Although some have high- lighted the use of contact lenses to examine the retina of pre-cataract patients, Dr. Charles noted many retinal problems cannot be reliably seen with a contact lens. retinal disease, such as drusen. That is because it can give the cataract surgeon the opportunity to review the number and frequency of anti- VEGF injections that they are re- ceiving. Many patients are given less than one injection each month, and research indicates results improve with greater injection frequency. "You want to make absolutely certain they are on track with that injection process," Dr. Charles said. Not all retinal specialists sup- ported such broad-based use of OCT in pre-cataract patients. Keith Warren, MD, Overland Park, Kansas, emphasized the impor- tance of taking a careful history in cataract patients. "If you talk to those patients in detail, what you will find out in many cases is their vision is out of proportion to the degree of cataract that they have—that their vision is less than what it should be based on the opacity of their lens," Dr. Warren said. "That would warrant getting an OCT." Another problem is that many cataract surgeons think that macular thickening seen on OCT is edema. "It may or may not be edema," Dr. Charles said. "Numerous people think that epimacular membranes, for example, pre-dispose to macu- lar edema, except there's really no evidence for that." Dr. Charles urged surgeons to personally examine every black and white section of such images for diabetic macular edema (DME). "The EMR people pitched the idea of taking the images into the EMR and having a photographer or technician pick an image—bad mistake," Dr. Charles said. "I can't tell you how many DME patients that I've looked at a section and said 'You're probably OK—hold on, these last two sections show there is edema.'" The size of the challenge facing cataract surgeons was illustrated by Timothy Olsen, MD, Atlanta, who noted that the Centers for Disease Control and Prevention projected about 620,000 U.S. cases of ad- vanced age-related macular degen- eration and 125,000 patients under treatment for it. It's important for cataract surgeons to know the amount of intermediate drusen that meets the criteria for recommending antioxi- dant vitamins with zinc. "You really want to communi- cate this risk," Dr. Olsen said. Among such patients in whom cataract surgeons would want to avoid surgery are those with in- traretinal hemorrhages with some exudate, large drusen, and opacities of the choroid. Such eyes need to go through 6 months of injections before they should consider cataract surgery, Dr. Olsen said. "You don't want to operate on an eye in relationship to an ac- tive new onset of wet AMD—even though it may be totally unrelated —because they are going to blame you," Dr. Olsen said. EW Editors' note: Dr. Charles has finan- cial interests with Alcon (Fort Worth, Texas). Dr. Warren has no financial interests related to this comments. Dr. Olsen has financial interests with iMacular Regeneration (Atlanta). OCT needed for all cataract patients Dr. Charles underscores the importance of obtaining OCT for all cataract patients as a way to avoid post-surgery vision surprises.

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